Articles Nurse staffing and education and hospital mortality in nine

Embargo: February 26, 2014—00:01 (GMT)
Version 1
This version saved: 10:49, 20-Feb-14
Nurse staffing and education and hospital mortality in nine
European countries: a retrospective observational study
Linda H Aiken, Douglas M Sloane, Luk Bruyneel, Koen Van den Heede, Peter Griffiths, Reinhard Busse, Marianna Diomidous, Juha Kinnunen,
Maria Kózka, Emmanuel Lesaffre, Matthew D McHugh, M T Moreno-Casbas, Anne Marie Rafferty, Rene Schwendimann, P Anne Scott,
Carol Tishelman, Theo van Achterberg, Walter Sermeus, for the RN4CAST consortium*
Background Austerity measures and health-system redesign to minimise hospital expenditures risk adversely affecting
patient outcomes. The RN4CAST study was designed to inform decision making about nursing, one of the largest
components of hospital operating expenses. We aimed to assess whether differences in patient to nurse ratios and
nurses’ educational qualifications in nine of the 12 RN4CAST countries with similar patient discharge data were
associated with variation in hospital mortality after common surgical procedures.
Methods For this observational study, we obtained discharge data for 422 730 patients aged 50 years or older who
underwent common surgeries in 300 hospitals in nine European countries. Administrative data were coded with a
standard protocol (variants of the ninth or tenth versions of the International Classification of Diseases) to estimate
30 day in-hospital mortality by use of risk adjustment measures including age, sex, admission type, 43 dummy
variables suggesting surgery type, and 17 dummy variables suggesting comorbidities present at admission. Surveys of
26 516 nurses practising in study hospitals were used to measure nurse staffing and nurse education. We used
generalised estimating equations to assess the effects of nursing factors on the likelihood of surgical patients dying
within 30 days of admission, before and after adjusting for other hospital and patient characteristics.
Findings An increase in a nurses’ workload by one patient increased the likelihood of an inpatient dying within
30 days of admission by 7% (odds ratio 1·068, 95% CI 1·031–1·106), and every 10% increase in bachelor’s degree
nurses was associated with a decrease in this likelihood by 7% (0·929, 0·886–0·973). These associations imply that
patients in hospitals in which 60% of nurses had bachelor’s degrees and nurses cared for an average of six patients
would have almost 30% lower mortality than patients in hospitals in which only 30% of nurses had bachelor’s degrees
and nurses cared for an average of eight patients.
Interpretation Nurse staffing cuts to save money might adversely affect patient outcomes. An increased emphasis on
bachelor’s education for nurses could reduce preventable hospital deaths.
Funding European Union’s Seventh Framework Programme, National Institute of Nursing Research, National
Institutes of Health, the Norwegian Nurses Organisation and the Norwegian Knowledge Centre for the Health
Services, Swedish Association of Health Professionals, the regional agreement on medical training and clinical
research between Stockholm County Council and Karolinska Institutet, Committee for Health and Caring Sciences
and Strategic Research Program in Care Sciences at Karolinska Institutet, Spanish Ministry of Science and
Constraint of health expenditure growth is an important
policy objective in Europe despite concerns about
adverse outcomes for quality and safety of health care.1,2
Hospitals are a target for spending reductions. Healthsystem reforms have shifted resources to provide more
care in community settings while shortening hospital
length of stay and reducing inpatient beds, resulting in
increased care intensity for inpatients. The possible
combination of fewer trained staff in hospitals and
intensive patient interventions raises concerns about
whether quality of care might worsen. Findings of the
European Surgical Outcomes Study3 across 28 countries
recently showed higher than expected hospital surgical
mortality and substantial between country variation in
hospital outcomes.
Nursing is a so-called soft target because savings can be
made quickly by reduction of nurse staffing whereas
savings through improved efficiency are difficult to
achieve. The consequences of trying to do more with less
are shown in England’s Francis Report,4 which discusses
how nurses were criticised for failing to prevent poor
care after nurse staffing was reduced to meet financial
targets. Similarly, results of the Keogh review5 of
14 hospital trusts in England showed that inadequate
nurse staffing was an important factor in persistently
high mortality rates. Austerity measures in Ireland and
Spain have been described as adversely affecting hospital
staffing too.6,7
Research that could potentially guide policies and
practices on safe hospital nurse staffing in Europe has
been scarce. Jarman and colleagues8 reported an Published online February 26, 2014
Published Online
February 26, 2014
See Online/Comment
*Members are listed at end of
Center for Health Outcomes
and Policy Research, University
of Pennsylvania School of
Nursing, Philadelphia, PA, USA
(Prof L H Aiken PhD,
D M Sloane PhD,
M D McHugh PhD); Centre for
Health Services and Nursing
Research, Catholic University
Leuven, Leuven, Belgium
(L Bruyneel MS,
K Van den Heede PhD, Prof
W Sermeus PhD); Faculty of
Health Sciences, University of
Southampton, Southampton,
UK (Prof P Griffiths PhD);
Department of Health Care
Management, WHO
Collaborating Centre for Health
Systems, Research and
Management, Berlin University
of Technology, Berlin, Germany
(Prof R Busse MD); Faculty of
Nursing, University of Athens,
Athens, Greece
(M Diomidous PhD);
Department of Health Policy
and Management, University
of Eastern Finland, Kuopio,
Finland (Prof J Kinnunen PhD);
Institute of Nursing and
Midwifery, Faculty of Health
Science, Jagiellonian University
Collegium Medicum, Krakow,
Poland (Prof M Kózka PhD);
Leuven Biostatistics and
Statistical Bioinformatics
Centre, KU Leuven, Leuven,
Belgium (Prof E Lesaffre PhD);
Nursing and Healthcare
Research Unit, Institute of
Health Carlos III, Madrid, Spain
(M T Moreno-Casbas PhD);
Florence Nightingale School of
Nursing and Midwifery, King’s
College, London (Prof
A M Rafferty PhD); Institute of
Nursing Science, Basel,
20/02/2014 10:49:32
(R Schwendimann PhD); School
of Nursing and Human
Sciences, Dublin City
University, Dublin, Ireland
(Prof P A Scott PhD); Medical
Management Centre,
Department of Learning,
Informatics, Management and
Ethics, Karolinska Institutet,
Stockholm, Sweden
(Prof C Tishelman PhD); and
Scientific Institute for Quality
of Healthcare, Radboud
University Nijmegen Medical
Center, IQ Healthcare, HB
Nijmegen, Netherlands
(T van Achterberg PhD)
Correspondence to:
Prof Linda H Aiken, Center for
Health Outcomes and Policy
Research, University of
Pennsylvania School of Nursing,
Philadelphia, PA 19104, USA
[email protected]
See Online for appendix
association between large proportions of auxiliary nurses 1 improvement of hospital care in Europe in the context of
(which implies a low overall mix of nursing skill) and scarce resources and health-system reforms.
high mortality in hospitals in England. Rafferty and
colleagues9 noted that low hospital mortality in England Methods
after common surgeries was associated with nurses each 5 Study setting
caring for few patients. Research in Belgium10 found Data for this observational study were from administrative
hospital mortality after cardiac surgery was significantly sources on hospital patients and characteristics of
lower in hospitals with lower patient to nurse staffing hospitals, and surveys of 26 516 bedside care professional
ratios and in hospitals with a higher proportion of nurses nurses done in 2009–10 in 300 hospitals in nine European
with bachelor’s education than in hospitals with higher 10 countries (Belgium, England, Finland, Ireland, the
staffing ratios and fewer nurses with bachelor’s education. Netherlands, Norway, Spain, Sweden, and Switzerland).
Likewise, data from a Swiss study11 suggested significantly Similar patient discharge data consistent with the patient
increased surgical mortality associated with inadequate mortality protocol were not available for three RN4CAST
countries (Germany, Poland, and Greece). The study
nurse staffing and poor nurse work environments.
This nascent but growing scientific literature about 15 included most adult acute care hospitals in Sweden,
nursing outcomes in Europe is complemented by Norway, and Ireland, and geographically representative
research from North America showing that improved samples of hospitals in the other countries.22
hospital nurse staffing is associated with low mortality.12
The European study protocol received ethical approval
Additionally, growing evidence exists that bachelor’s by the lead university, Catholic University of Leuven,
education for nurses is associated with low hospital 20 Belgium. Each grantee organisation in the nine
participating countries received ethical approval at the
Research into nursing has had little policy traction in institutional level to do nurse surveys and analyse
Europe compared with the USA where almost half the administrative data for patient outcomes. We also
50 states have implemented or are considering hospital obtained country level approvals to acquire and analyse
nurse staffing legislation.18,19 On the basis of findings 25 patient outcomes data.
showing improved outcomes for patients, the Institute of
Medicine recommended that 80% of nurses in the USA Outcomes
have a bachelor’s degree by 2020,20 and hospitals have We obtained patient mortality data for postoperative
responded with preferential hiring of bachelor’s nurses. patients discharged from study hospitals in the year
European decision makers might be unclear about the 30 most proximate to the nurse survey for which data were
applicability of research done in individual countries in available, which ranged between countries from 2007 to
Europe or North America to Europe more generally. 2009. Our analyses included patients aged 50 years or
Specifically, scientific evidence is needed to inform the older with a hospital stay of at least 2 days who
continuing European Union policy debate about underwent common general, orthopaedic, or vascular
harmonisation of professional qualifications for nurses.21 35 surgery, and for whom complete data were available for
RN4CAST, funded by the European Commission, was comorbidities present on admission, surgery type,
designed to provide scientific evidence for decision discharge status, and other variables used for risk
makers in Europe about how to get the best value for adjustment. We used the procedures published by
nursing workforce investments, and to guide workforce Silber and colleagues25 to define common surgeries and
planning to produce a nurse workforce for the future that 40 comorbidities (appendix). We selected common
would meet population health needs.22 Investigators of surgeries for study because almost all acute hospitals
the study of 488 hospitals in 12 European countries noted undertake them, risk adjustment procedures for
substantial variation between countries with regards to surgical patients have been well validated, and riskpatient to nurse workloads and the percentage of nurses related comorbidities can be more accurately
qualified at the bachelor’s level.23 These variations in 45 distinguished for surgical patients than for medical
nursing resources are important predictors of patients’ patients because they are present at admission by
satisfaction with their care and in nurses’ assessments of contrast with complications arising in the hospital. We
coded data in all countries with a standard protocol by
quality and safety of care.24
We aimed to assess whether differences in patient-to- use of variants of the ninth or tenth version of the
nurse workloads and nurses’ educational qualifications 50 International Classification of Diseases.26 Researchers
in nine of the 12 RN4CAST countries with similar patient are not able to validate coding in administrative hospital
discharge data are associated with variation in hospital discharge files. Countries can have validation protocols
mortality after common surgical procedures. The nine for administrative data but this information is not
countries are representative of variation in Europe with available. Findings of studies in Europe show that
respect to organisation, financing, and resources given to 55 routinely collected administrative data predict risk of
health services. The study’s findings provide previously hospital death with discrimination similar to that
unavailable evidence to guide important decisions about obtained from clinical databases.27 We restricted Published online February 26, 2014
20/02/2014 10:49:32
hospitals to those with 100 or more targeted patients. 1 generalised estimating approach and random intercept
The primary outcome measure was whether patients models using hierarchical linear modelling. Both
died in the hospital within 30 days of admission. Risk approaches took into account patients being nested
adjustment variables included patient age, sex, within hospitals, and in both types of models we
admission type (emergency or elective), 43 dummy 5 included dummy variables to allow for unmeasured
variables suggesting surgery type, and 17 dummy differences across countries. Because the results were
variables suggesting comorbidities present at ad­ almost identical, and the estimated effects of nursing
characteristics were the same in terms of their size and
mission, which are included in the Charlson index.28
Nurse staffing and education measures were derived importance, we show only the generalised estimating
from responses to surveys of nurses in each hospital with 10 results. We tested for the effects on mortality of an
the RN4CAST nurse survey instrument.22 The term nurse interaction between nurse staffing and education, which
refers to fully qualified professional nurses. In all was not significant and is not included in the results. All
countries except Sweden, hospitals were sampled in statistical analyses were done with SAS (version 9.2).
different regions, after which a variable number of adult
medical and surgical wards were randomly sampled in 15 Role of the funding source
each hospital, depending on hospital size (between two The sponsors of the study had no role in study design,
and six wards in each hospital in every country except data collection, data analysis, data interpretation, or
England, where all wards were sampled, up to a maximum writing of the report. The corresponding author had full
of ten). All nurses providing direct patient care in these access to all the data in the study and had final
wards were surveyed. In Sweden, all hospitals and all 20 responsibility for the decision to submit for publication.
medical and surgical wards were included by sampling all
medical surgical nurses nationally.
In the RN4CAST study, nurse staffing for each hospital We obtained mortality data for 422 730 patients; the
was calculated from survey data by dividing the number number of hospitals and surgical discharges varied
of patients by the number of nurses that each nurse 25 across countries (table 1). The percentage of surgical
reported were present on their ward on their last shift, patients who died in the hospital within 30 days of
and then averaging ratios across all nurse respondents in admission was 1·3% across the nine countries combined,
each hospital. Low ratios suggested more favourable and was lowest in Sweden and highest in the Netherlands
staffing. Collection of data for hospital nurse staffing (table 1).
directly from nurses avoided differences in administrative 30 Response rates for surveys of nurses ranged from less
reporting methods across countries and ensured that than 40% (2990 of 7741) in England, to nearly 84% (2804
only nurses in inpatient care roles are counted. We of 3340) in Spain, and averaged 62% (29 251 of 47 160)
measured nurse education by calculating the percentage across the nine countries. Differences in both nurse
of all nurses in each hospital that reported that the staffing and nurse education were large both between
highest academic qualification they had earned was a 35
bachelor’s degree or higher.
Statistical analyses
We estimated associations between nurse staffing and
nurses’ education and 30 day inpatient mortality for 40
patients before and after adjusting for additional hospital
characteristics and risk-adjusting for differences in
patient characteristics. Hospital characteristics included
country, bed size, teaching status, and technology; we
defined high technology hospitals as those that 45
undertook open heart surgery or organ transplantation.
We included the hospital nurse work environment,
measured by the Practice Environment Scale of the
Nursing Work Index, as a control variable like in
previous studies of nursing and mortality.15 Patient 50
characteristics included age, sex, admission type, type of
surgery (with 43 dummy variables for the specific
surgery types), and presence of 17 comorbidities
(appendix). Because individual patient outcomes were
modelled with a combination of hospital and patient 55
characteristics, we estimated the effects of different
characteristics with population average models using a
Mean discharges per Deaths/discharges
hospital (range)
1493 (413–4794)
1017/88 078 (1·2%)
2603 (868–6583)
1084/78 045 (1·4%)
1516 (175–3683)
303/27 867 (1·1%)
738 (103–1997)
292/19 822 (1·5%)
466/31 216 (1·5%)
1419 (181–2994)
1468 (432–4430)
518/35 195 (1·5%)
1382 (186–3034)
283/21 520 (1·3%)
1304 (295–4654)
828/80 800 (1·0%)
1308 (158–3812)
590/40 187 (1·5%)
1308 (103–6583)
5381/422 730 (1·3%)
Only hospitals with more than 100 surgical patient discharges were included in
the analyses. Data shown are for discharged patients for whom information
about 30 day mortality, age, sex, type of surgery, and comorbidities were
complete. Data were missing for those characteristics for less than 4% of all
Table 1: Hospitals sampled in nine European countries with patient
discharge data, numbers of surgical patients discharged, and numbers
of patient deaths (RN4CAST data) Published online February 26, 2014
20/02/2014 10:49:32
countries and between hospitals within each country
(table 2). In Spain and Norway, all nurses had bachelor’s
degrees. The mean age of the patient sample was 68 years
(SD=10); table 3 shows other patient characteristics. Of
Nurse staffing
(patients to nurse)
Nurse education
(% of nurses with
bachelor’s degrees)
Mean (SD)
Mean (SD)
10·8 (2·0)
55% (15)
8·8 (1·5)
28% (9)
7·6 (1·4)
50% (10)
6·9 (1·0)
58% (12)
7·0 (0·8)
31% (12)
5·2 (0·8)
100% (0)
12·7 (2·0)
100% (0)
7·6 (1·1)
54% (12)
7·8 (1·3)
10% (10)
8·3 (2·4)
52% (27)
Means, SDs, and ranges are estimated from hospital data—eg, the 59 hospitals in
Belgium have a mean patient-to-nurse ratio of 10·8, and the patient-to-nurse
ratio ranges across those 59 hospitals from 7·5 to 15·9. Similarly, the 31 hospitals
in Switzerland have, on average, 10% bachelor’s nurses, and the percent of
bachelor’s nurses ranges across those 31 hospitals from 0% to 39%.
Table 2: Nurse staffing and education in nine European countries
Number (%)
189 815 (45%)
Emergency admissions
141 584 (34%)
Inpatient deaths within 30 days of admission
5381 (1·3%)
Surgical categories
General surgery
162 974 (39%)
Orthopaedic surgery
220 301 (52%)
Vascular surgery
39 455 (9%)
15 297 (4%)
Cerebrovascular disease
7400 (2%)
Congestive heart failure
10 274 (2%)
Chronic pulmonary disease
28 373 (7%)
5744 (1%)
Diabetes with complications
6478 (2%)
Diabetes without complications
50 (0%)
Metastatic carcinoma
17 911 (4%)
Myocardial infarction
12 002 (3%)
Mild liver disease
Our findings shows that an increase in nurses’ workload
increases the likelihood of inpatient hospital deaths, and
an increase in nurses with a bachelor’s degree is
40 associated with a decrease in inpatient hospital deaths
(panel). Findings of the RN4CAST study showed more
5953 (1%)
Moderate or severe liver disease
1354 (0%)
Paraplegia and hemiplegia
2043 (1%)
Peptic ulcer disease
2323 (1%)
Peripheral vascular disease
12 452 (3%)
Renal disease
10 085 (2%)
Connective tissue disease or rheumatic disease
6962 (2%)
Table 3: Characteristics of surgical patients (n=422 730) in the study
Partly adjusted models
Fully adjusted model
OR (95% CI)
OR (95% CI)
p value
Education 1·000
35 450 (8%)
439 800 patients studied more than 50% had orthopaedic
surgeries, whereas roughly four in ten underwent
general surgeries, and slightly less than one in
10 underwent vascular surgeries. The most common
5 comorbidities were diabetes without complications,
chronic pulmonary disease, metastatic carcinoma, and
Table 4 shows results of modelling the effects of the two
nursing factors (staffing and education) on mortality after
10 adjustment for differences across countries in mortality
(in the partly adjusted model) and for differences in the
full set of potentially confounding factors (in the fully
adjusted model). After we considered severity of illness of
the patients and characteristics of the hospitals (teaching
15 status and technology) in the adjusted model, both nurse
staffing and nurse education were significantly associated
with mortality (table 4). The odds ratios (ORs) suggest that
each increase of one patient per nurse is associated with a
7% increase in the likelihood of a surgical patient dying
20 within 30 days of admission, whereas each 10% increase in
the percent of bachelor’s degree nurses in a hospital is
associated with a 7% decrease in this likelihood. These
associations suggest that patients in hospitals in which
60% of the nurses had bachelor’s degrees and nurses cared
25 for an average of six patients would have almost 30% lower
mortality than patients in hospitals in which only 30% of
the nurses had bachelor’s degrees and nurses cared for an
average of eight patients. We worked out this 30%
reduction (reduction in mortality by a factor of 0·70) by
30 applying (and multiplying) the reciprocal of the OR
associated with nurse staffing across two intervals (from
eight to six patients per nurse) and the OR associated with
nurse education across three intervals (from 60% to
30%)—ie, 1/1·068 × 1/1·068 × 0·929 × 0·929 × 0·929=0·703.
p value
The partly adjusted models estimate the effects of nurse staffing and nurse
education separately while controlling for unmeasured differences across
countries. The fully adjusted model estimates the effects of nurse staffing and
nurse education simultaneously, controlling for unmeasured differences across
countries and for the hospital characteristics (bed size, teaching status, technology,
and work environment), and patient characteristics (age, sex, admission type, type
of surgery, and comorbidities present on admission). OR=odds ratio.
Table 4: Partly and fully adjusted odds ratios showing the effects of
nurse staffing and nurse education on 30 day inpatient mortality Published online February 26, 2014
20/02/2014 10:49:32
variation in hospital mortality after common surgical 1
Panel: Research in context
procedures in European hospitals than is generally
understood. Variation in hospital mortality is associated
Systematic review
with differences in nurse staffing levels and educational
We searched PubMed for original research articles published in
qualifications. Hospitals in which nurses cared for fewer 5 English between Jan 1, 1985, and Aug 10, 2013, with the search
patients each and a higher proportion had bachelor’s
terms (separately and in combination): “nursing”, “staffing”,
degrees had significantly lower mortality than hospitals
“administrative data”, “outcomes”, “mortality”, “European
in which nurses cared for more patients and fewer had
Union”, and “cross-national” and “international.” We also did a
bachelor’s degrees. These findings are similar to those of
manual search based on bibliographies of papers we found.
studies of surgical patients in US and Canadian hospitals 10 Studies linking nursing and clinical patient outcomes were
in which similar measures and protocols were used.14,15
restricted in Europe to one country studies8–11 and to research in
Our finding that each 10% increase in the proportion of
North America.12–17 In Europe, cross-national studies assessing
nurses with a bachelor’s degree in hospitals is associated
how hospital nursing affects patient outcomes are restricted to
with a 7% decrease in mortality is highly relevant to the
assessment of outcomes based on patient or nurse report
recent decision by the European Parliament (Oct 9, 2013) 15 rather than objective clinical outcomes.24
to endorse two educational tracks for nurses—one
vocational and one higher education.21 In view of the
We report the first study to use detailed information about
RN4CAST findings, the goal of standardised qualifications
nursing workforce such as staffing and education level to
of professionals as expressed in the Bologna process is a
long way off from being achieved. Our findings support 20 investigate how these factors affect patient mortality across
countries in Europe. We relied on unique data from direct-care
the recent EU decision to recognise professional nursing
nurses collected with a common method across many hospitals
education within institutions of higher education starting
in different countries. We used a standardised approach across
after 12 years of general education. However, our results
countries to measure and adjust the risk of mortality on the
challenge the decision to continue to endorse vocational
nursing education after only 10 years of general education 25 basis of administrative records. Findings of our analysis of
300 hospitals in nine countries show that an increase in nurses’
because this training might hamper access to higher
workloads by one patient increases the likelihood of inpatient
education for nurses in some countries—eg, Germany
hospital mortality by 7%, and a 10% increase in bachelor’s
where no nurses in the 49 hospitals studied in RN4CAST
degree nurses is associated with a decrease in odds on mortality
had a bachelor’s degree.23
The RN4CAST finding that improved hospital nurse 30 by 7%. These findings emphasise the risk to patients that could
emerge in response to nurse staffing cuts and suggest that an
staffing is associated with decreased risk of mortality
increased emphasis on bachelor’s education for nurses could
might be inconvenient in the present difficult financial
reduce preventable hospital deaths.
context and amid health-system reforms to shift
resources to community-based settings. Nevertheless,
this study is the largest and most rigorous investigation 35 Our study has several limitations. We assessed one
of nursing and hospital outcomes in Europe up to now, outcome, mortality, and only in patients undergoing
and has robust results. Our findings reinforce those of common general surgeries. Our measure of education
smaller studies in Europe,8–11 and a large body of relied on each country’s definition of bachelor’s
international published work.12,14 Our data suggest a safe education for nurses, which differs by country. Our
level of hospital nurse staffing might help to reduce 40 global measure of nurse staffing shows nurse workloads
surgical mortality, as called for by the European Surgical across all shifts, and might be skewed in some hospitals
if nurses working at night (when patient-to-nurse ratios
Outcomes Study.3
Beyond improvements in care, investments in nursing are higher than in the day) responded to our survey at
could make good business sense. In the USA, each US$1 different rates than nurses on day shifts. The models we
spent on improvements to nurse staffing was estimated 45 used to measure associations allowed us to control for
to return a minimum of $0·75 economic benefit to the unmeasured differences in mortality across countries
investing hospital, not counting intangible benefits.30 and for measured differences across patients and
Furthermore, a move from less qualified licensed hospitals, but unmeasured confounding factors at the
vocational nurse hours to qualified professional nurse individual, hospital, and community level could have
hours is estimated to save lives and money.31 Improved 50 affected our results. We cannot link the care of individual
nurse staffing in US hospitals is associated with patients to individual nurses. Additionally, mortality
significantly reduced readmission rates, which is outcomes for patients were taken from the year that most
compelling in view of financial penalties in 2013 to closely matched the nurse survey year, but because of
2225 hospitals for excessive readmissions.32 Although lags in patient data availability, the two data sources were
hospital finance and payment policies differ between the 55 not always perfectly aligned. Finally, our data are crossUSA and Europe, the underlying goal of better value for sectional and provide restricted information about
investments is the same.33 Published online February 26, 2014
20/02/2014 10:49:32
Additional research in Europe is needed to establish 1 research between Stockholm County Council and Karolinska Institutet,
whether our multicountry findings can be replicated for Committee for Health and Caring Sciences and Strategic Research
Program in Care Sciences at Karolinska Institutet (CT), Spanish
high mortality surgeries and for medical patients; and Ministry of Science and Innovation (FIS PI080599; TM-C). We thank
whether in Europe, like in the USA, nursing is related to a Tim Cheney for analytic assistance and the Norwegian Patient Register,
range of adverse outcomes that contribute to high costs. 5 which sourced patient data for the study in Norway.
Longitudinal studies of panels of hospitals would be References
especially valuable to help to establish causal associations 1 Karanikolos M, Mladovsky P, Cylus J, et al. Financial crisis,
austerity, and health in Europe. Lancet 2013; 381: 1323–31.
between changes in nursing resources and outcomes for
2 Rechel B, Wright B, Edwards N, Dowdeswell B, McKee M, eds.
patients. Comparative effectiveness research is needed to
Investing in hospitals of the future. European Observatory on
Health Systems and Policies: World Health Organization, 2009.
identify what workforce investments return the greatest 10
value, and under what circumstances. Research beyond 3 Pearse RM, Moreno RP, Bauer P, et al, and the European Surgical
Outcomes Study (EuSOS) group for the Trials groups of the
simple mortality outcomes would be welcome to help to
European Society of Intensive Care Medicine and the European
Society of Anaesthesiology. Mortality after surgery in Europe:
establish standards of care by which performance of
a 7 day cohort study. Lancet 2012; 380: 1059–65.
health-care organisations could be more fully assessed. In
4 Francis R. Report of the Mid Staffordshire NHS Foundation Trust
a context of widespread health-system redesign and 15
Public Inquiry. London: The Stationery Office, 2013.
reforms, increased funding for studies of health workforce 5 Keogh B. Review into the quality of care and treatment provided by
14 hospital trusts in England: overview report. 2013. http://www.
investments could result in high-value health care.
In summary, educational qualifications of nurses and
keogh-review-final-report.pdf (accessed Jan 13, 2014).
patient-to-nurse staffing ratios seem to have a role in the 6 Thomas S, Keegan C, Barry S, Layte R. The Irish health system and
the economic crisis. Lancet 2012; 380: 1056–57.
outcomes of hospital patients in Europe. Previous 20
findings from RN4CAST show that patients are more 7 Legido-Quigley H, Otero L, la Parra D, Alvarez-Dardet C,
Martin-Moreno JM, McKee M. Will austerity cuts dismantle the
likely to express satisfaction with hospital care when
Spanish healthcare system? BMJ 2013; 346: f2363.
nurses care for fewer patients each. To add to these 8 Jarman B, Gault S, Alves B, et al. Explaining differences in English
hospital death rates using routinely collected data. BMJ 1999;
findings, our data suggest that evidence-based
318: 1515–20.
investments in nursing are associated with reduction in 25 9 Rafferty AM, Clarke SP, Coles J, et al. Outcomes of variation in
hospital deaths.
hospital nurse staffing in English hospitals: cross-sectional analysis of
survey data and discharge records. Int J Nurs Stud 2007; 44: 175–82.
10 Van den Heede K, Lesaffre E, Diya L, et al. The relationship
LHA, WS, LB, MM, PG, RB, and MTM-C did the literature search. LHA,
between inpatient cardiac surgery mortality and nurse numbers
WS, DMS, KVdH, AMR, PG, MM, RB, AS, and CT designed the study.
and educational level: analysis of administrative data.
WS, LHA, KVdH, RB, PG, MD, JK, MK, MTM-C, AMR, RS, AS, CT, and
Int J Nurs Stud 2009; 46: 796–803.
TVA collected data. LHA, DMS, LB, MM, WS, and TVA analysed data.
11 Schubert M, Clarke SP, Aiken LH, de Geest S. Associations
All of the authors contributed to data interpretation, writing, and
between rationing of nursing care and inpatient mortality in Swiss
revision of the report.
hospitals. Int J Qual Health Care 2012; 24: 230–38.
12 Kane RL, Shamliyan TA, Mueller C, Duval S, Wilt TJ.
RN4CAST consortium
The association of registered nurse staffing levels and patient
Walter Sermeus (Director), Koen Van den Heede, Luk Bruyneel,
outcomes: systematic review and meta-analysis. Med Care 2007;
Emmanuel Lesaffre, Luwis Diya (Belgium, Catholic University Leuven); 35
45: 1195–204.
Linda Aiken (Codirector), Herbert Smith, Douglas Sloane (USA,
13 Aiken LH, Clarke SP, Cheung RB, Sloane DM, Silber JH.
University of Pennsylvania); Anne Marie Rafferty, Jane Ball, Simon Jones
Educational levels of hospital nurses and surgical patient mortality.
(UK, King’s College London); Peter Griffiths (UK, University of
JAMA 2003; 290: 1617–23.
Southampton); Juha Kinnunen, Anneli Ensio, Virpi Jylhä (Finland,
14 Estabrooks CA, Midodzi WK, Cummings GG, Ricker KL,
University of Eastern Finland); Reinhard Busse, Britta Zander,
Giovannetti P. The impact of hospital nursing characteristics on
Miriam Blümel (Germany, Berlin University of Technology); John Mantas,
30-day mortality. Nurs Res 2005; 54: 74–84.
Dimitrios Zikos, Marianna Diomidous (Greece, University of Athens);
15 Aiken LH, Cimiotti JP, Sloane DM, Smith HL, Flynn L, Neff DF.
Anne Scott, Anne Matthews, Anthony Staines (Ireland, Dublin City
Effects of nurse staffing and nurse education on patient deaths in
University); Ingeborg Strømseng Sjetne (Norwegian Knowledge Centre
hospitals with different nurse work environments. Med Care 2011;
for the Health Services) Inger Margrethe Holter (Norwegian Nurses
49: 1047–53.
Organization); Tomasz Brzostek, Maria Kózka, Piotr Brzyski (Poland,
16 Blegen MA, Goode CJ, Park SH, Vaughn T, Spetz J. Baccalaureate
Jagiellonian University Collegium Medicum); Teresa Moreno-Casbas,
education in nursing and patient outcomes. J Nurs Adm 2013;
Carmen Fuentelsaz-Gallego, Esther Gonzalez-María, Teresa Gomez-Garcia 45
43: 89–94.
(Spain, Institute of Health Carlos III); Carol Tishelman, Rikard Lindqvist,
17 Kutney-Lee A, Sloane DM, Aiken LH. An increase in the number of
Lisa Smeds (Sweden, Karolinska Institute); Sabina De Geest,
nurses with baccalaureate degrees is linked to lower rates of
postsurgery mortality. Health Aff (Millwood) 2013; 32: 579–86.
Maria Schubert, René Schwendimann (Switzerland, Basel University);
Maud Heinen, Lisette Schoonhoven, Theo van Achterberg (Netherlands,
18 American Nurses Association. Safe nurse staffing laws in state
legislatures. 2013.
Radboud University Nijmegen Medical Centre).
StateLegislation.aspx (accessed Jan 13, 2014).
Conflicts of interest
19 Aiken LH, Sloane DM, Cimiotti JP, et al. Implications of the
We declare that we have no conflicts of interest.
California nurse staffing mandate for other states. Health Serv Res
2010; 45: 904–21.
20 Institute of Medicine (IOM). The future of nursing: leading change,
European Union’s Seventh Framework Programme (FP7/2007–2013,
advancing health. Washington: The National Academies, 2011.
grant agreement no. 223468; WS and LHA), National Institute of
21 European Parliament. Recognition of professional qualifications
Nursing Research, National Institutes of Health (R01NR04513; LHA), the
and administrative cooperation through the Internal Market
Norwegian Nurses Organisation and the Norwegian Knowledge Centre
Information System. Article 31 amended. http://www.europarl.
for the Health Services (IMH), Swedish Association of Health, the regional agreement on medical training and clinical
6 Published online February 26, 2014
20/02/2014 10:49:32
TA-2013-408#BKMD-17 (accessed Jan 24, 2014).
22 Sermeus W, Aiken LH, Van den Heede K, et al, and the RN4CAST
consortium. Nurse forecasting in Europe (RN4CAST): Rationale,
design and methodology. BMC Nurs 2011; 10: 6.
23 Aiken LH, Sloane DM, Bruyneel L, Van den Heede K, Sermeus W,
and the RN4CAST Consortium. Nurses’ reports of working
conditions and hospital quality of care in 12 countries in Europe.
Int J Nurs Stud 2013; 50: 143–53.
24 Aiken LH, Sermeus W, Vanden Heede K, et al. Patient safety,
satisfaction, and quality of hospital care: cross-sectional surveys of
nurses and patients in 12 countries in Europe and the United
States. BMJ 2012; 344: e1717.
25 Silber JH, Kennedy SK, Even-Shoshan O, et al. Anesthesiologist
direction and patient outcomes. Anesthesiology 2000; 93: 152–63.
26 Quan H, Sundararajan V, Halfon P, et al. Coding algorithms for
defining comorbidities in ICD-9-CM and ICD-10 administrative
data. Med Care 2005; 43: 1130–39.
27 Aylin P, Bottle A, Majeed A. Use of administrative data or clinical
databases as predictors of risk of death in hospital: comparison of
models. BMJ 2007; 334: 1044.
28 Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of
classifying prognostic comorbidity in longitudinal studies:
development and validation. J Chronic Dis 1987; 40: 373–83.
29 Zabalegui A, Macia L, Márquez J, et al. Changes in nursing
education in the European Union. J Nurs Scholarsh 2006; 38: 114–18.
30 Dall TM, Chen YJ, Seifert RF, Maddox PJ, Hogan PF. The economic
value of professional nursing. Med Care 2009; 47: 97–104.
31 Needleman J, Buerhaus PI, Stewart M, Zelevinsky K, Mattke S.
Nurse staffing in hospitals: is there a business case for quality?
Health Aff (Millwood) 2006; 25: 204–11.
32 McHugh MD, Berez J, Small DS. Hospitals with higher nurse
staffing had lower odds of readmissions penalties than hospitals
with lower staffing. Health Aff (Millwood) 2013; 32: 1740–47.
33 Quentin W, Scheller-Kreinsen D, Blümel M, Geissler A, Busse R.
Hospital payment based on diagnosis-related groups differs in
Europe and holds lessons for the United States.
Health Aff (Millwood) 2013; 32: 713–23.
55 Published online February 26, 2014
20/02/2014 10:49:32